Physical Therapy Management of Dysmenorrhea and Dyspareunia: A Case Study

1. Physical Therapy Management of Dysmenorrhea and Dyspareunia: A Case Study Meghan W. Swenck, PT, DPT April 9, 2010

2. Introduction to Dysmenorrhea • Defined: painful menstruation • Characterized by: painful breasts, depression and irritability, pain in the LQ, heavy menstrual flow • May be associated with musculoskeletal pain • Predisposing factors: age under 30, low BMI, 1st menses before age 12, nulliparity, long cycle, premenstrual syndrome, hx sexual abuse, sterilization

3. Secondary +pelvic pathology Initial onset years after menses begins Pain reproducible Pain lasts 48-72hrs days per episode Painful areas vary Primary vs. Secondary Dysmenorrhea Primary • No identifiable pelvic pathology • Initial onset 6-12mo. after menses begins • Cyclical pain w/menses, lasts 48-72hrs each episode • Cramping in suprapubic region

4. Secondary Dysmenorrhea • Most commonly associated with endometriosis, an inflammatory condition in which endometrial tissue grows outside of the uterus and forms adhesions in the pelvic cavity • Pain: “dull, aching, pulling” unilaterally • Common Agg factors: sex, pelvic exams, BM

5. Question #1 For a patient c/o abdominal and back pain with medical history of endometriosis, which of the following muscles do you suspect may have adhesions and/or pain upon palpation? A. Obturator Internus B. Psoas C. Iliacus D. Pelvic Floor Muscles (PFM) E. All of the above

6. Iliacus, Psoas, PFM, OI

7. Dysmenorrhea Management • Primary: (80-90% effectiveness) • Oral contraceptives • NSAIDs or OTC anti-inflammatories • Prostaglandin synthease inhibitors • Secondary: • Treat/manage underlying pathology • Endometriosis: pain meds, massage/STM of adhesions, stretching routines

8. Introduction to Dyspareunia • Definition: painful penetration • Digital exam (PT) • Speculum exam (GYN) • Tampon • Sex • Primary: Pain at first attempt to penetrate • Secondary: Pain after hx of successful attempts

9. Dyspareunia: Contributing Factors? What started first? • Review medical hx and consider: • Referred pain (IBS, IC) organ or another ms • Overactive PFM, vulvodynia, vaginissmus • Abdominal adhesions (C sections?, tummy tuck?, IBS, Chrohn’s, IC) • Skin, bladder, vaginal, or bowel infections • Medication side effects

10. Anticipates pain at future encounter Dyspareunia Theory Pain meds Psychological counseling Pain with intercourse Guarded PFM and postures Negative response to sexual intimacy Stretching programs, PT

11. Anatomy and Physiology of the Pelvic Floor • Layer 1: Superficial Genital Muscles • Intermediate muscles: Compressor Urethrae, Sphincter Urethrae • Layer 2: Pelvic Diaphragm • Functions: • Support organs and spine • Sexual function • Continence

12. Initial Evaluation: Subjective • 21 yo female • Referral from OBGYN for “Chronic pelvic pain” • Abdominal and pelvic pain x 6mo. • About 1 month ago, pain increased and Pt experienced an abnormally heavy menstrual cycle

13. What other subjective information would you like to know about her symptoms? • Nature of pain: deep ache • Duration of pain: up to 24 hrs in abdomen • Intensity of pain: moderate to severe • Aggravating Factors: prolonged standing @work, sexual intercourse • Relieving Factors: sitting, gentle ex, heat packs to belly, abstaining from intercourse

14. Subjective Continued • Medical and Social History: chronic Epstein-Barr virus, breast reduction surgery, history of small ovarian cysts, lost 100lbs rapidly after stopping steroids at age 17, began menses at age 13, home schooled 5th-11th grade, depression, counseling • Medical Tests for this Dx: vaginal US: “normal uterus and multifollicular ovaries” • Medications: IVIG every 3 weeks, Loestrin Fe, Naproxen, daily multivitamin, Vicodin

15. Subjective Continued • Job: blockbuster 8hr shifts, babysitter, nursing student (on summer vacation) • Living situation: with boyfriend • Family support:Father and brother live in town, mother deceased • History with sexual partner: painfree intercourse in past

16. #2 Which of these subjective facts determine whether she has primary or secondary dyspareunia? • A. History of depression • B. Has experienced pain-free sexual intercourse in the past • C. vaginal US stating “normal uterus and multifollicular ovaries” • D. Both B and C

17. Involuntary Functions Pelvic Floor Evaluation Voluntary Functions Relaxation Push down w/o holding breath (should happen when voiding or having BM) Contraction squeeze and lift as if stopping urine “kegel” Relaxation release your squeeze Contraction Cough test, response to increased intra-abdominal pressure

18. Question #3 Using what you now know about pelvic floor function: Which of the previous 4 functions do you predict a patient with overactive pelvic floor dysfunction would have the most difficulty performing during examination?

19. Involuntary Functions #3 Overactive Pelvic Floor Dysfunction? Voluntary Functions Relaxation Push down w/o holding breath Contraction squeeze and lift as if stopping urine Relaxation release your squeeze Contraction Cough test, response to increased intra-abdominal pressure A B C D

20. Pelvic Floor Dysfunction Categories • Normal • Overactive: poor voluntary and involuntary relaxation, may also have weakness due to increased tone (urge incontinence, pain) • Underactive: poor voluntary contraction (stress incontinence, organ prolapse) • Non-functioning: poor voluntary and involuntary contraction and relaxation (pain, incontinence)

21. What would you like to look at in your objective examination? • ROM- lumbar, hips • Joint mechanics – lumbosacral , pelvis • Palpation – abdomen, pelvis, low back • MMT- LQ screen • Pelvic Floor Assessment

22. Initial Evaluation: Objective • Palpation: • +jump sign L iliacus, guarding R iliacus • Tenderness L abdominals • Decreased mobility R abs medial to lateral • Joint mechanics and mobility: • Type I positional fault R SB/L ROT lumbar spine w/sacral torsion • MMT: • Hip add, abd 3+/5 B • Hip flex, IR, ER, knee flex 4-/5 B

23. Objective: Pelvic Floor Assessment • Externally: • Pain to palpation @ 3,4, 9 o'clock • Internally: • +reproduction of abdominal pain in R levatorani group (LA) and obturatorinternus (OI)* • Moderate tenderness in L LA and OI w/o referral • Voluntary Contraction: 3/5 strength, 10 sec hold x 2 reps • Voluntary Relaxation: difficulty relaxing/slow • Involuntary Contraction: intact • Involuntary Relaxation: unable

24. Question #4 A positive jump sign indicates: • A. A nervous patient • B. A weak muscle • C. A Trigger Point • D. A normal objective finding

25. Patient Goals: Pain free work activities Pain free sexual intercourse Decrease and manage menstrual cycle pain Outcome measures and Goals • Female Sexual Function Index (FSFI) • 19 item self-report measure (higher is better) • Asks about sexual activity, sexual intercourse, and sexual stimulation • Patient reports of function

26. Prognosis? GOOD! Young Motivated Research support Past Tx Success with this Dx

27. Disablement Model

28. #5 What is the domain of Physical Therapist Practice within the Disablement Model? • A. Pathology • B. Impairment • C. Functional Limitation • D. Disability • E. B and C

29. Impairments Hip strength PFM strength Impaired joint mechanics Tight and tender ms in hips, abdomen and pelvic floor Pain Functional Limitations Prolonged standing for work activites Exercising Sexual Intercourse Painful menstrual cycles Impairments and Functional Limitations

30. Pain with prolonged positioning Classifying Symptoms Inflammatory Affective Ischemic Mechanical Increased pain during menses and ovarian cysts Lumbar spinedysfunction Depression

31. Interventions • Impairment: Lumbosacral spine dysfunction • Intervention: • Muscle Energy Techniques and Direct Mobilizations • Lumbosacral spine for type I dysfunctions • Sacrum for torsions • Pas to lumbar and sacroiliac joints

32. Interventions • Impairments: iliacus, psoas, OI, LA ms tightness and guarding • Interventions: • Soft Tissue Mobilization • Strumming • Cross-hand release • Scooping • Ischemic compression • Thiele’s Massage

33. Interventions –Soft Tissue Restrictions • HEP: • Stretching • Iliacus with arm reach overhead • Pt to try PFM self-stretching with own tools; later purchased a crystal wand

34. Interventions • Impairment: Pain • Interventions: • Moist Heat • Lower abdomen in the evenings (HEP) • In combination with TENS in clinic • TENS to abdomen • 100pps, 250usec pulse width, 15min • Criss-cross set-up • Home TENS prescribed

35. Interventions • Impairment: weakness in the hip musculature • Interventions: • Strengthening • Sidelying hip abduction “CLAM” • PFM exs to improve circulation, strength, and support for the pelvic organs • Pt to walk dog, resume Wii Fit as able

36. Treatment Progression • Visit 1 (evaluation): • Muscle Energy Techniques to L-S spine • MHP to abdomen • Pt Education • Visits 2-3: • Soft Tissue Mobilizations to psoas, iliacus, abdominal region • TENS to abdomen • Iliacus stretching • HEP: test out vaginal penetration with vibrator

37. Treatment Progression • Visits 4-8: • Internal exam of the pelvic floor • Soft tissue treatments to the pelvic floor muscles • Continued soft tissue treatments to abdominals • Continued TENS and heat in clinic • Pt experienced a menstrual cycle-minimal pain!

38. Treatments Continued • Visit 9: Had intercourse with about 6 hours of soreness! • Visits 10-14: • Progressed HEP with crystal wand self-stretching • Added CLAM exercise for HIP ER strengthening • Issued Home TENS unit • Restarted birth control pills

39. Multidisciplinary Care • PT and MD discussed having Pt restart birth control • Patient was still working with psychological counselor • Good support system- father, brother, boyfriend

40. Outcome • 14 visits over 8 weeks • 90% improvement, per self-report • FSFI score 33/36 • Reported minimal post-sexual intercourse pain if she used TENS • Using crystal wand to self stretch every 3 days • Returned to daily walking and started a new job in elder care • Had experienced minimal pain with recent menstrual cycle

41. Take Home Points • Use of orthopedic skills in women’s health • Pay attention to psychosocial aspects • Know your limits as a PT and coordinate care with physician, counselor, etc.

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44. Questions or Comments?